The case presented here is of a 72-year-old man with an acute proximal aortic hematoma. He was hospitalized and underwent close monitoring and blood pressure control. Typical aortic dissection developed during his hospital admission. This case emphasizes the importance of frequent follow-up imaging during medical therapy of patients with aortic intramural hematoma. However, the frequency of imaging is yet to be determined.

An iatrogenic intramural hematoma (IMH) localized in the ascending aorta is a rare and potentially life-threatening complication following percutaneous coronary intervention (PCI). We describe the case of an ascending aortic IMH after the PCI of an anomalous right coronary artery. Early extension of the hematoma was observed during transesophageal echocardiography; the patient underwent successful surgical repair.

Aortic intramural hematoma (AIH) is part of the acute aortic syndrome together with aortic dissection and penetrating aortic ulcer. AIH represents up to 12% of acute aortic syndrome cases and has a clinical presentation indistinguishable from that of classic aortic dissection. A patient with AIH is presented and the diagnostic, prognostic and therapeutic implications of the disease are discussed.

OBJECTIVE: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). METHODS: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. RESULTS: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow-up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow-up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three-year survival rate did not show significant differences between both groups (82 +/- 6% in IMH vs. 75 +/- 7% in AD, P = 0.37). CONCLUSION: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow-up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.

A 60-year-old woman with severe chest pain and ECG diagnostic for acute transmural ischemia was transferred to cath lab for primary PTCA. After procedure, transesophageal echocardiography (TEE) views revealed an intramural haematoma extending from the ostium of the RCA throughout the sino-tubular junction. These findings and the stable clinical conditions of patient guided us to a conservative therapeutic approach. A TEE study, performed 5 days after admission, showed a complete resolution of intramural haematoma. A waiting strategy can be a valid therapeutic option in selected patients with iatrogenic haematoma and TEE is a useful diagnostic tool for clinical decision making.

The acute painful aortic syndrome is a clinical enity observed in four conditions: dissection, intramural haematoma, penetrating atheromatous ulcer and aneurysm. The diagnosis is based on three imaging techniques: echocardiography, CT scan and magnetic resonance imaging. They have displaced angiography which is incomplete and even dangerous in some cases. Their sensitivity and specificity are comparable in terms of diagnosis. However, each has a specificity. Transthoracic and transoesophageal echocardiography are useful in the diagnosis, the quantification and analysis of the mechanism of aortic regurgitation which may complicate dissection. CT scan visualises the collateral arteries, investigates the physiopathological mechanisms of poor perfusion syndromes and detects parietal fissuration. Magnetic resonance imaging is better adapted to the study of stable forms. In conclusion, transoesophageal echocardiography is a rapid and reliable diagnostic method, it can be used as the investigation of first intention and is essential in patient management. The use of other imaging modes is only required in some cases. The choice, guided by the clinical history, depends on its aptitude to complete the missing or partial data of transoesophageal echocardiography.

PURPOSE: To present a rare case of abdominal aortic intramural hematoma with penetrating ulcer. CASE REPORT: A 68-year-old hypertensive lady was admitted with chest pain. An echo Doppler abdominal study showed a 2.5-cm-diameter abdominal aorta with periaortic blood flow. Urgent computed tomography documented a 4-cm aneurysmal dilatation, 4 cm long, at the infrarenal level of the inferior mesenteric artery origin, which appeared on the angiogram as a very short lateral bleb. At elective open laparotomy, no true abdominal atherosclerotic aneurysm was found in the retroperitoneal space, but rather, an intramural hematoma with ulcer. An aortobi-iliac graft was inserted, and the patient was discharged with a good outcome. Histological examination of the explanted tissue confirmed adventitial calcifications, organized thrombus in the hematoma, and intimal neovascularization. CONCLUSIONS: Considering the pathology, this case was more appropriately treated with open surgery, although endovascular repair was not excluded as an option.

Aortic intramural hematoma or atypical aortic dissection is an aortic dissection without intimal tear nor flow communication and it may be the first step of a typical dissection. We describe five cases, in which transesophageal echocardiography detected intramural hematoma of the aorta. Transesophageal echocardiography is a safe, accurate and specific method that allows bedside diagnosis as well as follow-up of patients with hematoma of the aorta.

OBJECTIVES: This study sought to describe the ability of transesophageal echocardiography (TEE) to document the presence of penetrating atherosclerotic aortic ulcers and their complications. BACKGROUND: TEE has greatly enhanced our ability to assess patients with suspected aortic disease. However, the utility of this technique in the diagnosis of penetrating atherosclerotic aortic ulcers is still undefined. METHODS: TEE was performed prospectively in 194 patients to evaluate aortic disease. Twelve patients with the diagnosis of aortic ulcers or their complications were specifically studied. The diagnosis was confirmed by pathologic studies in six patients and by an additional diagnostic technique (angiography, computed tomography or magnetic resonance imaging) in the other six. All 12 patients were hypertensive and presented with chest or back pain; the mean age was 65 years (range 56 to 79). The initial working diagnosis was acute aortic dissection in nine patients. Aortic ulcers were located in the descending thoracic aorta in eight patients, the aortic arch in two and the ascending aorta in two. RESULTS: TEE could detect aortic ulcers or their complications in 10 patients but failed to detect these lesions in the remaining 2 (1 with aortic ulcers in the distal ascending aorta and 1 with aortic ulcers in the aortic arch). In four patients, aortic ulcers were detected as a calcified focal outpouching of the aortic wall and were associated with concomitant aneurysmal dilation of the aorta in two patients and with a small localized intramural hematoma in one. TEE visualized a partially thrombosed pseudoaneurysm complicating an aortic ulcer in the descending thoracic aorta of two patients. Four patients had an aortic ulcer complicated by a "limited aortic dissection" in the descending aorta that could be detected by TEE. Five patients underwent operation, two because of aneurysmal dilation of the aorta and three because of aortic dissection; two patients died of aortic rupture; the remaining five did well (11-month follow-up) without operation. CONCLUSIONS: Aortic ulcers should be included in the differential diagnosis of chest or back pain, especially in elderly hypertensive patients. These ulcers and their complications may be recognized by TEE.

We report a patient whose clinical and echocardiographic findings were compatible with a diagnosis of aortic intramural hematoma, but magnetic resonance imaging demonstrated a prominent and localized periaortic deposit of fat as the cause of the transesophageal echocardiographic appearance. This is a significant caveat that must be borne in mind when interpreting echocardiographic images obtained in patients with suspected intramural aortic hematomas.

BACKGROUND: Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Transesophageal echocardiography is the current standard diagnostic imaging modality in many medical centers. Aortic intramural hematoma is a variant of aortic dissection whose natural history and prognosis have not been well studied. We performed transesophageal echocardiography in patients with aortic intramural hematoma to determine the echocardiographic characteristics and echocardiographic evolution of this lesion, impact on patient management, and patient outcome. METHODS AND RESULTS: Twenty-one consecutive patients with aortic intramural hematoma confirmed anatomically (four patients) or with an additional diagnostic imaging technique (17 patients) underwent a transesophageal echocardiographic examination. Fifteen patients with longstanding hypertension had chest or back pain, and the intramural hematoma was visualized in the ascending aorta (n = 4), along the whole aorta (n = 4), in the descending aorta (n = 6), or in the aortic arch (n = 1). The thickening of the aortic wall was crescentic. Patients with ascending aortic intramural hematoma had the following results: two patients died suddenly, three patients underwent surgery because of increased aortic wall thickening (one patient) or secondary intimal tear (two patients), and the remaining three patients had regression of the hematoma. Patients with hematoma confined to the descending aorta and the patient with aortic arch involvement (n = 7) had a different result: one patient died from aortic rupture and the remaining six patients did well. Six patients had a traumatic aortic injury, and the intramural hematoma was located along the descending thoracic aorta. The thickening of the aortic wall was circular in five patients and crescentic in one. Three of these patients had normalized thickness of the aortic wall on follow-up transesophageal echocardiographic studies. The other three patients died from multiorgan system failure. Aortography showed a reduction of the diameter of the aortic lumen in four patients; diameter in the remaining 17 patients was normal. CONCLUSIONS: Aortic intramural hematoma can be detected and monitored by transesophageal echocardiography but not by aortography. Two types of aortic intramural hematoma can be distinguished: (1) traumatic of good prognosis and (2) nontraumatic, which can be an early stage of the classic aortic dissection, with bad prognosis in cases involving the ascending aorta.

OBJECTIVES. This study describes the transesophageal echocardiographic and follow-up findings in patients with aortic intramural hemorrhage. BACKGROUND. Localized aortic intramural hemorrhage resulting in layered thickening of the aortic wall seems to represent a variant of acute aortic dissection without communication or a typical moving intimal flap. In autopsy studies this variant, attributed to a rupture of the vasa vasorum, has been described in 5% to 10% of patients with dissection. METHODS. In a prospective transesophageal echocardiographic study in patients with aortic dissection performed between 1986 and 1991, the diagnosis of intramural hemorrhage was established in 15 of 114 patients and either confirmed anatomically (7 patients) with an additional diagnostic imaging technique or on the basis of clear follow-up changes (8 patients). RESULTS. Elderly patients (mean age 70 years) with a history of hypertension were affected by this variant of dissection. The ascending aorta was involved in 3 patients and the descending aorta in 12. The longitudinal extent varied between 3 and 20 cm, and wall thickness varied between 0.7 and 3 cm. Classic aortic dissection developed in five patients (33%) and rupture in four (27%). Regression of aortic wall thickening was noted in two patients, whereas three patients became asymptomatic without apparent wall changes (33%). Surgery was performed in 5 patients, whereas medical therapy was continued in 10. During a mean follow-up period of 11 months, eight patients (53%) died because of complications of the aortic disease. CONCLUSIONS. Intramural hemorrhage represents a variant of aortic dissection and may be an early finding in patients who develop classic aortic dissection or rupture. Transesophageal echocardiography is an excellent method for the detection of intramural hemorrhage and for monitoring these patients.

BACKGROUND. Intramural hematoma of the thoracic aorta (IMH) is a diagnosis of exclusion and represents spontaneous, localized hemorrhage into the wall of the thoracic aorta in the absence of bona fide aortic dissection, intimal tear, or penetrating atherosclerotic ulcer. This process may arise from primary vasa vasorum hemorrhage within the aortic media or rupture of an atherosclerotic plaque. The clinical presentation of patients with IMH mimics that of acute aortic dissection; moreover, considerable diagnostic confusion exists despite the use of many different imaging modalities. The optimal mode of management of patients with IMH (medical versus medical plus surgical) remains problematic because of the paucity of information available. METHODS AND RESULTS. Thirteen patients with IMH were managed at two medical centers between 1983 and 1992. Patients with IMH caused by giant penetrating atherosclerotic ulcers were specifically excluded. There were 8 women and 5 men (mean age, 70 years [range, 54 to 82 years]). The admitting clinical diagnosis was acute aortic dissection, and all patients had a history of hypertension. There was no evidence of aortic dissection or intimal disruption as assessed by computed tomographic (CT) scan (n = 11), aortography (n = 10), magnetic resonance imaging (MRI) scan (n = 9), transesophageal echocardiography (TEE) (n = 6), or intravascular ultrasound (n = 1). The diagnosis of IMH was established by exclusion. The descending thoracic aorta was involved in 10 cases and the ascending/arch in 3. Conservative medical management was attempted initially. All 3 patients with IMH involving the ascending aorta ultimately required operative intervention, and 2 individuals died; 2 of 10 patients with descending aortic involvement eventually underwent surgery. Average hospital stay was 11 days; the mean follow-up interval for discharged patients was 29 months. CONCLUSIONS. IMH is a distinct pathological entity, should not be confused with aortic dissection, and probably will be identified more frequently in the future. All patients with IMH should be monitored carefully and treated with aggressive antihypertensive therapy. Frequent serial assessment is necessary using TEE or MRI/CT scans. Based on this small experience, patients with ascending/arch IMH, ongoing pain, or IMH expansion should probably undergo early graft replacement. Patients with IMH involving the descending thoracic aorta who have no evidence of progression and become pain free can probably be treated conservatively but require antihypertensive therapy and serial aortic imaging surveillance indefinitely.